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When Billing E&M Codes

Remember:

  • Federal law requires that all expenses paid by Medicare, including expenses for Evaluation and Management (E/M) services, are for services that are "reasonable and medically necessary."
  • Medical necessity of E/M services depends on the condition of the patient, the services required to treat that patient at that time, and are generally expressed in two ways: frequency of services and intensity of service (Current Procedural Terminology [CPT] level).
  • Medicare's determination of the medical necessity of a service is separate from the determination that the E/M service was rendered as billed, or that the claim was billed correctly.
  • Medicare reviews claims for medical necessity largely through the experience and judgment of clinician coders. The results of the reviews are based on the documentation of the patient's problem(s) and what services the treating clinician performed, in addition to the tools provided in CPT and by the Centers for Medicare & Medicaid Services (CMS).
  • At audit, Medicare will deny or downcode E/M services that, in its judgment, exceed the patient's documented needs.
  • Submit the claim to Medicare for the service that was medically necessary and documented.

It is the accurate documentation of the services rendered for the patient's needs at the time that determine the level of E&M code to be selected, not the volume of documentation. That is why the thorough documentation of the patient's condition, the services rendered, and the reason(s) for those services is so important.

Thus, when billing an E&M service, document the patient's condition, what medically necessary service(s) were provided, and the reasoning for those services, based on the patient's needs at that time.

Select the most appropriate Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code for that service - the code that describes the medically necessary service provided.

CHECK YOUR RECORDS FOR THE FOLLOWING …

  • Records are legible; all abbreviations and symbols will be easily recognized by reasonable clinicians.
  • The patient's name and the date of service appear on every page of the record (including the back side of double sided forms).
  • The date of service on the record matches the date of service in the claim.
  • The identity and professional credentials of all persons who contributed to the service and/or the record clearly indicate which portion(s) of the service and/or record was contributed by whom.
  • Information in the record clearly supports all diagnoses reported on the claim.
  • Information in the record clearly demonstrates all of the work described by the code(s) and/or modifiers reported on the claim were performed.
  • All procedures reported are clearly documented.
  • Evaluation and Management (E/M) services reported on the same day as a procedure are clearly documented, medically necessary, significant and separate from the procedure.
  • The record of services performed "incident to" a physician service demonstrates the link between the employee's work and the physician's service.
  • The record of services split/shared by a physician and non-physician practitioner demonstrates the face-to-face encounter and contribution to patient management by each practitioner involved.

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